1.ANSWER A – An elevation in white blood cells may indicate that the client hasa n infection, which would likely require rescheduling of the surgical procedure.The other values are slightly abnormal, but would not be likely to cause post-operative problems for a knee arthroscopy. Focus: Prioritization
2.ANSWER C– Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain
occur, it will cause unnecessary anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization
3.ANSWER D – Hypoxia and deoxygenation of the red blood cells are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control and hydration are also important interventions for this client and should be accomplished rapidly. Vaccination may help prevent future sickling
episodes by decreasing the risk of infection, but it will not help with the current sickling crisis.
4.ANSWER A– An experienced nursing assistant would have been taught how to obtain a stool specimen for the Hematoccult slide test, because this is a common screening test for hospitalized clients. Having the client sign an informed consent should be done by the physician who will be doing the colonoscopy. Administration of medications and checking for allergies are within the scope of practice for licensed nursing staff. Focus: Delegation
5.ANSWER C– A nurse who works in the PACU will be familiar with the monitoring needed for a client who has just returned from a procedure like a colonoscopy, which requires conscious sedation. The other clients require more experience with various types of hematologic disorders and would be better to assign to nursing staff who regularly work on the medical – surgical unit. Focus: Prioritization
6.ANSWER A– Clients with pancytopenia are at higher risk for infection. The client with digoxin toxicity presents the least risk of infecting the new client. Viral pneumonia, shingles, and cellulites are infectious processes.
7.ANSWER B – The joint pain that occurs in sickle cell crisis is caused by obstruction to blood flow by the sickled red blood cells. The appropriate therapy for this client would be application of moist heat to the joints to cause
vasodilation and improve circulation. Because control of pain is a priority during sickle cell crisis, there is no need to restrict all visitors or to check the temperature every 2 hours. Focus: Prioritization
8.ANSWER C – Because aspiring will decrease platelet aggregation, clients with thrombocytopenia should not use aspirin routinely. Client teaching about his should be included in the care plan. Bruising is consistent with the client’s admission problem of thrombocytopenia. Soft, dark brown stools indicate that there is no frank blood in the bowel movements. A decrease in appetite is common with chemotherapy, and more assessment is indicated. Focus: Prioritization
9.ANSWER B– When a hemophiliac client is at high risk for bleeding, for example, after a motor vehicle accident, the priority intervention is to maximize the availability of clotting factors. The other orders also should be implemented rapidly, but do not have as high a priority. Focus:Prioritization
10.ANSWER A – Clients taking warfarin are advised to avoid making sudden diet changes, because changing the oral intake of foods high in vitamin K (such as green leafy vegetables and some fruits) will have an impact on the effectiveness of the medication. The other statements suggest that further teaching may be indicated, but more assessment for teaching needs is indicated first. Focus:Prioritization
11.ANSWER C – Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care. The other data also indicate the need for rapid intervention, but improvement of oxygenation is the most urgent need.Focus: Prioritization
12.ANSWER C – Most assessment about what the client means is needed before any interventions can be planned or implemented. All of the other statements indicate a conclusion that the client is afraid of dying of Hodgkin’s disease.
13.ANSWER D – Any temperature elevation in a neutropenic client may indicate the presence of a life-threatening infection, so actions such as blood cultures and antibiotic administration should be initiated quickly. The other clients need to e assessed as soon as possible, but are not critically ill. Focus: Prioritization
14.ANSWER B – Nursing assistant education include routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of client abilities, and nutrition planning are roles appropriate to RN practice.
15.ANSWER C – The client’s symptoms indicate that a transfusion reaction may be occurring so the first action should be to stop the transfusion. Chills are an indication of a febril
e reaction, so warming the client is not appropriate. Checking the client’s temperature and administration of oxygen are also appropriate actions if a transfusion reaction is suspected; however, stopping the transfusion
is the priority. Focus: Prioritization
16.ANSWER A – Subcutaneous administration of epoetin is within the LPN/LVN scope of practice. The other clients require skills (blood transfusion and client teaching about phlebotomy and bone marrow aspiration) that are more appropriate to RN-level practice.
17.ANSWER D – The lack of plantar flexion may indicate spinal cord compression, which should be evaluated and treated immediately by the physician to prevent further loss of function. While chronic bone pain, hyperuricemia, and the presence of Bence-Jones protein in the urine all are typical
18.ANSWER B – Because the spleen has an important role in the phagocytosis of microorganisms, the client is at higher risk for severe infection after a splenectomy. Medical therapy, such as antibiotic administration, is usually
indicated for any symptoms of infection. The other information also indicates the need for more assessment and intervention, but prevention and treatment of infection are the highest priorities for this client.
19.ANSWER C – Infusion of IV fluids is indicated in RN education, and the new RN would also have had experience with this as part of an orientation to the medical unit. Administration of potent immunosuppressive medications, assessment for subtle indications of infection, and client teaching are more complex tasks that should be delegated to more experienced RN staff members. Focus:Delegation
20.ANSWER C – Because many aspects of nursing are need to be modified to prevent infection when a client has a low ANC, care should be provided by the staff member with the most experience with neutropenic clients. The other staff members have the education required to care for this client, but are not as clinically experienced. When making acute care client assignments for LPN staff members, they must work under the supervision of an RN. The LPN in this case would report to the RN assigned to the client. Focus:Assignment
21.ANSWER D – The neutropenic client is at increased risk for infection, so the LTC charge nurse needs to know this in order to make decisions about the client room assignment and to plan care. The other information also will impact on planning for client care, but the charge nurse needs the information about neutropenia before the client is transferred. Focus: Prioritization
22.ANSWER A – Fatal hyperkalemia may be caused by tumor lysis syndrome, a potentially serious consequence of chemotherapy in acute leukemia. The othersymptoms also indicate a need for further assessment or intervention, but are not as critical as the elevated potassium level.
23.ANSWER B – A non-tender swelling in this area (or near any lymph node) may indicate that he client has developed lymphoma, a possible adverse effect of immunosuppressive therapy. The client should receive further evaluation immediately. The other symptoms may also indicate side effects of cyclosporine (gingival hyperplasia, nausea, paresthesia) but do not indicate the need for immediate action. Focus:Prioritization
24.ANSWER D –Skin care is included in nursing assistant education and job description. Assessment and client teaching are more complex tasks that should be delegated to registered nurses. Use of lotions to the irradiated area is usually avoided during radiation therapy. Focus:Delegation
25.ANSWER A – The newly admitted client should be assessed first, because the baseline assessment and plan of care need to be completed. The other clients also need assessments or interventions, but do not need immediate nursing care. Focus:Prioritization